maintaining compliance documentation doug stringfield, chfm george volz, chfm
DESCRIPTION
Maintaining Compliance documentation Doug Stringfield, CHFM George Volz, ChfM. Maintaining Compliance Documentation. Cast. Centers for Medicare & Medicaid Services (CMS) Healthcare Facilities Accreditation Program The Joint Commission Det Norske Veritas. More Cast. - PowerPoint PPT PresentationTRANSCRIPT
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MAINTAINING COMPLIANCE DOCUMENTATION
DOUG STRINGFIELD, CHFMGEORGE VOLZ, CHFM
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Maintaining Compliance
Documentation
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CAST
•Centers for Medicare & Medicaid Services (CMS)•Healthcare Facilities Accreditation Program •The Joint Commission•Det Norske Veritas
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MORE CAST
•State Fire Marshal Title 153•HHS - Title 175•NDOL- Chapter 48•NDEQ – Chapter 46
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AND STILL MORE CAST
•City Agencies•Board•Physicians•Department•Patient & Families
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AND STILL MORE CAST
• SWPPP - Title 119•Waste Water - Title 123•Waste - Chapter 126• Hazardous waste Title 128• And others too numerous to mention………………….
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STAR OF THE SHOW
YOU
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WHAT Compliance Process
What applies to your facility?
What is the desired performance?
What documentation is required?
What improvements should be made?
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WHAT Centers for Medicare and Medicaid Services (CMS)
• CFR 42
• 624 pages
• Chapter 482.41
• Conditions of Participation
• Broad range of coverage
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WHAT State Fire Marshal—Title 153
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WHAT State Fire Marshal—Title 153
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WHAT State Fire Marshal—Title 153
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WHAT State Fire Marshal—Title 153
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WHAT State Fire Marshal—Title 153
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WHEN
NOW Compliance
DailyWeekly
MonthlyAnnually
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READ
AND DO
How do you know if you comply?
TJCCMS
DNVHFAP
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HOW
TJC
Environment of Care
EC.01.01.01
Someone manages the risks
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HOW
TJC
Environment of Care
EC.02.01.01
Hospital manages Safety and Security
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HOW
TJC
Environment of Care
EC.02.02.01
Hazardous Materials and Waste
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HOW
TJC
Environment of Care
EC.02.03.01 EP 4
Unobstructed exits
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HOW
TJC
Environment of Care
EC.02.03.01 EP 9
Written Fire Plan
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HOWTJC
Environment of Care
EC.02.03.05
Fire Safety Equipment
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HOW
TJC
Environment of Care
EC.02.05.01 EP 2
Utility Inventory
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HOWTJC
Environment of Care
EC.02.05.01 EP 3
Utility Maintenance
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HOWTJC
Environment of Care
EC.02.05.01 EP 4
Utility Maint. Intervals
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HOWTJC
Environment of Care
EC.02.05.01 EP 6
Ventilation Systems
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HOW
TJC
Environment of Care
EC.02.05.01 EP 9
Utility Disruptions
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HOWTJC
Environment of Care
EC.02.05.03 EP 2
Using Emergency Power
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HOW
TJC
Environment of Care
EC.02.05.03 EP 4
Elevator Power
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HOW
TJC
Environment of Care
EC.03.01.01
The Role of People
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HOWTJC
Life Safety
LS.01.01.01 EP2
Statement of Conditions
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HOW
TJC
Life Safety
LS.01.01.01 EP3
PFI
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HOW
TJC
Life Safety
LS.01.01.01 EP4
Other Inspections
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HOW
TJC
Life Safety
LS.01.02.01
Interim Life Safety
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HOWTJC
LIFE SAFETY
LS.02.01.35
FIRE EXTINGUISHING
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Panel Discussion
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THE END
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